Bloody hell!: venous sheath hemorrhage

Ruby Vee, BSN · Jun 14, 2018

So, I basically need help figuring out how the heck my patient got into this situation in the first place. Had a fem art line next to a venous sheath. Stopcocks were off to the patient preventing bleeding and I never touched the art line or sheath that night since he had a brachial art line I was drawing from. I go to change my pressure setup and the patient is bleeding profusely from the sheath. I immediately apply pressure, but the patient loses nearly 700ccs of blood before we can pull the line and get a fem stop. Intensivist comes in to help and says stopcocks are turned the wrong way now - which must have happened when we were applying pressure, otherwise , the patient would have bled out a lot sooner during my shift - I made sure in my initial assessment they were off. So, what I'm trying to figure out is how the eff did this happen?? I don't think I did anything wrong, but just thinking about it has kept me up at night.

Was the femoral art line transduced? Was there a pressure set up to the femoral arterial line? If there was a pressure set up and the stopcocks turned on to the patient and to the pressure (off to the port), there would not have been any bleeding and you could have transduced both lines. (It's been the policy of every ICU where I've ever worked that if you have an arterial line, you transduce it.) Was the patient heparinized? Had he just moved or bent his leg? Often when there's sudden and "inexplicable" bleeding, it's because the patient was moving, bending or playing with his venous sheath. I don't understand what exactly is meant by the stopcocks turned the "wrong way", but if the line was transduced and the port capped off, turning the stopcocks shouldn't have caused bleeding.

Nervous_nurse · Jun 14, 2018

Thanks for your response. Fem sheath was never capped because patient had come up from OR unstable- emergent lvad - and anesthesia leaves them uncapped downstairs. The venous sheath wasn't transduced but the art line In the same fem was. I assessed that the stopcocks were off when patient arrived. The next time I looked was to change my pressure setup and that's when I found the bleeding. The sheath was never touched and the patient wasn't that mobile. The only thing I can think is that somehow he/she was bleeding around the line...

AJJKRN · Jun 15, 2018

How long in between checking?

Nervous_nurse · Jun 15, 2018

It had been several hours, but as I said, I never accessed the line and the patient was sedated and not moving.

AJJKRN · Jun 15, 2018

It had been several hours, but as I said, I never accessed the line and the patient was sedated and not moving.

I was only asking because I was curious in the difference in facility protocols...we have to do frequent checks like crazy even with several patients per our protocols.

Nervous_nurse · Jun 15, 2018

Well, after this happened I'm thinking we should make it a protocol too!

AJJKRN · Jun 15, 2018

Well, after this happened I'm thinking we should make it a protocol too!

I would suggest then to include a cap on how many patients a nurse is allowed to have in said protocol or you are going to be up the same creek and the facility won't have to back you since you didn't follow protocol. Wish I didn't even have to suggest it though since it should be a given!

WestCoastSunRN, MSN, CNS · Jun 15, 2018

Did the patient only bleed out or was there retroperitoneal as well? Sounds like a possible coag problem -- you don't mention bleeding anywhere else though. But I'm thinking the bleeding was going on slowly for some time -- so just wondering what the site felt and looked like all in that groin and flank area.

offlabel · Jun 15, 2018

"I go to change my pressure setup and the patient is bleeding profusely from the sheath. I immediately apply pressure, but the patient loses nearly 700ccs of blood before we can pull the line and get a fem stop. Intensivist comes in to help and says stopcocks are turned the wrong way now - which must have happened when we were applying pressure, otherwise , the patient would have bled out a lot sooner during my shift"

1. Odd coincidence or incredible luck that you caught it when you did. How do you know it was nearly 700 cc? Was the patient unstable?

2. That kind of blood loss doesn't come from "around" a venous sheath. That was through the sheath. You should have been able to see the blood coming out of it, which would have given you an idea if it was coming through the stopcock or around it (the stopcock having been loosened/nearly disconnected).

3. Pulling the sheath without definitively knowing the cause of the bleeding was risky. If the stopcock was coming off or if it was turned the wrong way, it would have been a simple matter to fix and not have the hassle of dealing with a freshly pulled groin sheath.

MunoRN, RN · Jun 15, 2018

I'm not clear from your description if you're saying blood was coming from the sheath itself and that this was because the stopcock had failed? It would be highly unusual for a stopcock to fail allowing for the free flow of blood, but if that was the case it should have been clamped externally rather than pulling the sheath.

Ruby Vee, BSN · Jun 16, 2018

It had been several hours, but as I said, I never accessed the line and the patient was sedated and not moving.

We always had a protocol of checking every 15 minutes X 4, every 30 minutes X 4 and then hourly. I cannot imagine a scenerio in which I wouldn't check it for several hours. Even if the patient came back from the Cath Lab on the previous shift, I would still be checking it hourly. (Even on the Med/Surg floor where we'd get stable post cath patients.)